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The IDEAS Project: evaluating complexity in maternal and newborn health in Ethiopia, Nigeria and India. Joanna Schellenberg  12.45-2, Bennett Room, Friday 15 November, Keppel Street, WC1E 7HT. Outline. Background, motivation Objectives, research questions Selected methods and results

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slide1

The IDEAS Project: evaluating complexity in maternal and newborn health in Ethiopia, Nigeria and India

Joanna Schellenberg 12.45-2, Bennett Room, Friday 15 November, Keppel Street, WC1E 7HT

outline
Outline
  • Background, motivation
  • Objectives, research questions
  • Selected methods and results
  • Technical Resource Centre
  • Who we are
  • Highlights and challenges
slide3

IDEAS: Measurement, learning & evaluation of Bill & Melinda Gates Foundation grants in 3 countries

  • UP Community Mobilization
  • L10K
  • COMBINE
  • Sure Start

Credit: Agnes Becker

  • Society for Family Health

Credit: Neil Spicer

Credit: Bill & Melinda Gates Foundation

Credit: BilalAvan

  • Manthan
  • Community-based Newborn Care
  • MaNHEP

Credit: Society for Family Health

Credit BMGF

Credit: Manthan

  • North-East Nigeria
  • Better Birth
  • Uttar Pradesh, India
  • PACT
  • Ethiopia

Credit: Pact

slide4

Hadiza

Northeast Nigeria

Rani

Uttar Pradesh, India

Abrihet

Ethiopia

  • India
  • 1 in 170
  • Lifetime risk of maternal mortality[1]
  • Nigeria
  • 1 in 29
  • Lifetime risk of maternal mortality[1]
  • Ethiopia
  • 1 in 67
  • Lifetime risk of maternal mortality[1]

[1] 2010 World Bank: http://data.worldbank.org/indicator/SH.MMR.RISK

slide5

Hadiza

Northeast Nigeria

Rani

Uttar Pradesh, India

Abrihet

Ethiopia

UK

1 in 4600

Lifetime risk of maternal mortality

  • India
  • 1 in 170
  • Lifetime risk of maternal mortality[1]
  • Nigeria
  • 1 in 29
  • Lifetime risk of maternal mortality[1]
  • Ethiopia
  • 1 in 67
  • Lifetime risk of maternal mortality[1]

[1] 2010 World Bank: http://data.worldbank.org/indicator/SH.MMR.RISK

ideas objectives
IDEAS objectives
  • To build capacity for measurement, learning & evaluation.
  • To characterise innovations.
  • To measure efforts to enhance interactions between families & frontline workers and increase the coverage of critical interventions.
  • To explore scale-up of maternal and newborn health innovations
  • To investigate the impact on coverage and survival of maternal and newborn health innovations implemented at scale.
  • To promote best practice for policy.

Test the

Bill & Melinda Gates Foundation’s maternal and newborn health Theory of Change

bmgf maternal newborn health strategy theory of change
BMGF Maternal & Newborn Health Strategy Theory of change

Improved maternal

and newborn survival

Innovation

Interaction

Intervention

Community-based approach to enhancing health, new to the context

Enhanced interactions between families and frontline workers

Increased coverage of life-saving interventions

Scale-up

An innovation is increased in reach to benefit a greater number of people over a wider geographical area

slide8

An innovation is a approach to improve maternal and newborn health that is new to the setting.

Evidence-based, life-saving interventions*

Interactions

between families

and frontline

workers

*Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health.

PMNCH & Aga Khan University, 2011

http://www.who.int/pmnch/knowledge/publications/201112_essential_interventions/en/index.html

slide9

What are the innovations?

Do innovations enhance interactions and increase life-saving intervention coverage? If so, how?

Improved maternal

and newborn survival

Innovation

Interaction

Intervention

Community-based approach to enhancing health, new to the context

Enhanced interactions between families and frontline workers

Increased coverage of life-saving interventions

To what extent do scaled-up innovations affect coverage of life-saving interventions and survival?

How and why does scale-up happen?

Scale-up

An innovation is increased in reach to benefit a greater number of people over a wider geographical area

slide10

Call Centre

  • Society for Family Health
  • HEW training and supervision
  • Last 10 Kilometers
  • Safe Childbirth Checklist
  • Better Birth

What are the innovations?

Credit: Society for Family Health

Credit: BilalAvan

Credit: Manthan

  • Districts, Uttar Pradesh, India
  • Zones, Ethiopia
  • Local Government Areas, Gombe & Adamawa state, North-East Nigeria
characterising grantee innovations
Characterising grantee innovations
  • Individual Awareness-raising and Behaviour Change
  • Community Mobilisation
  • FLW Capacity-Strengthening
  • FLW Motivation
  • Job-aids to Enhance Provision
  • Infrastructure Development
  • Operational Enhancement

Types of innovation

What are the innovations?

Demand

Supply

  • Questions linking to the Theory of Change
    • What are the types of innovation?
    • What are the innovations?
    • How do the innovations enhance frontline worker interactions?
    • What kind of enhancement?
    • What is the geographic scope and timing?
slide13

Pathway analysis: community-level neonatal sepsis management in Ethiopia (provisional)

What are the innovations?

comment
Comment

What are the innovations?

  • Reveals gaps in funding, lack of integration, commonalities …
  • Pathways and process evaluations
    • Theory of change for each innovation
    • Monitoring data central
    • Basis for developing implementation strength measure
slide17

Do innovations enhance interactions and increase life-saving intervention coverage? If so, how?

Improved maternal

and newborn survival

Innovation

Interaction

Intervention

Community-based approach to enhancing health, new to the context

Enhanced interactions between families and frontline workers

Increased coverage of life-saving interventions

Scale-up

An innovation is increased in reach to benefit a greater number of people over a wider geographical area

slide18

How do enhanced interactions lead to an increase in critical interventions?

    • Qualitative work, 2014
  • Cost-effectiveness
    • Economic modelling
  • Surveys of households, frontline workers and health facilities.
  • Before & after, intervention & comparison areas.
  • Tracking contextual factors.
  • Baseline 2012, endline 2014+

Do innovations enhance interactions and increase life-saving intervention coverage? If so, how?

interactions coverage study area uttar pradesh india
Interactions & coverage study area: Uttar Pradesh, India

Uttar Pradesh, 2010:

MMR: 440/100,000

NMR: 45/1,000

interactions coverage study area gombe state nigeria
Interactions & coverage study area: Gombe State, Nigeria

Nigeria, 2010:

MMR: 840/100,000

NMR: 39/1,000

interactions coverage study area ethiopia
Interactions & coverage study area: Ethiopia

Ethiopia, 2010:

MMR: 470/100,000

NMR: 35/1,000

frequency of interactions women with a birth in last 12 months
Frequency of interactions Women with a birth in last 12 months

Do innovations enhance interactions and increase life-saving intervention coverage? If so, how?

slide23
Post-natal care processes: reported content of care amongst newborns who had at least one post-natal contact within 48 hours of birth

Do innovations enhance interactions and increase life-saving intervention coverage? If so, how?

coverage of live saving interventions newborn women with a birth in last 12 months
Coverage of live-saving interventions: newbornWomen with a birth in last 12 months

Do innovations enhance interactions and increase life-saving intervention coverage? If so, how?

*Don’t know responses excluded

comment1
Comment

Do innovations enhance interactions and increase life-saving intervention coverage? If so, how?

  • Challenges
    • Time frame different for all the innovations
    • No integration of demand and supply side investments
slide26

Improved maternal

and newborn survival

Innovation

Interaction

Intervention

Community-based approach to enhancing health, new to the context

Enhanced interactions between families and frontline workers

Increased coverage of life-saving interventions

How and why does scale-up happen?

Scale-up

An innovation is increased in reach to benefit a greater number of people over a wider geographical area

slide27

Aims

  • To understand how to catalyse scale-up of externally funded MNH innovations and identify factors enabling or inhibiting their scale-up

Scale-up definition

  • Increasing the geographical reach of externally funded MNH innovations to benefit a greater number of people beyond grantee programme districts

Methods

  • 150 in-depth stakeholder interviews in 3 geographies in 2012
  • Follow-up in 2014
  • Constituencies in the field of MNH:
    • Government, development agencies, civil society
    • Foundation grantees and programme officers
    • Academics/researchers, professional associations, experts

How and why does scale-up happen?

to catalyse scale up
To catalyse scale-up:
  • Integrate scale-up within plans and resources
  • Design for scale
  • Build organisational capacity
  • Advocate with government decision makers
  • Generate and communicate strong evidence
  • Align with government
  • Ensure government involvement
  • Harmonise efforts with development partners and implementers
  • Invoke policy champions and networks of allies/partners
  • Support and build government capacity for scale-up
  • Work with community leaders and others to stimulate diffusion

How and why does scale-up happen?

slide29

Harmonisation and alignment

‘People in India are not combining their expertise...instead of wasting time reinventing the wheel we need to come together...’

  • Donors and grantees embracing country coordination mechanisms helps to:
    • Strengthen government strategic coordination of external programmes
        • Coordinate evidence presented to government
        • Share learning to strengthen innovations:
  • Innovations aligned with government policies:
  • Grantees’ evidence aligned with government targets and indicators:

‘What matters is the government’s priority area and if your idea’s not there, no matter how much you push, replication and scale-up are almost impossible’

How and why does scale-up happen?

‘...the ministry wants to see the results – how the innovation can contribute to the ministry and the health sector...’

comment2
Comment
  • Challenge of high-quality data collection at a distance
  • Link to quantitative work has been challenging

How and why does scale-up happen?

slide31

Improved maternal

and newborn survival

Innovation

Interaction

Intervention

Community-based approach to enhancing health, new to the context

Enhanced interactions between families and frontline workers

Increased coverage of life-saving interventions

To what extent do scaled-up innovations affect coverage of life-saving interventions and survival?

Scale-up

An innovation is increased in reach to benefit a greater number of people over a wider geographical area

slide32

Where community-based maternal and newborn health innovations have been implemented on a large scale beyond grantee areas, what is the effect on coverage of critical interventions and how does this depend on implementation strength? What survival impact can be expected?

  • Implementation strength: the pooled effect of dose, duration, specificity, and intensity of an intervention – in order to determine how much implementation effort is needed to achieve a meaningful change in coverage and health outcomes.

To what extent do scaled-up innovations affect coverage of life-saving interventions and survival?

slide33

Coverage of ITNs in children under 5 years in July-August 1999 by time since start of social marketing programme(Schellenberg Lancet 2004)

Mortality reduction and coverage of treated nets

Examples of dose-response approach from other public health evaluations

To what extent do scaled-up innovations affect coverage of life-saving interventions and survival?

our approach
Our approach
  • Victora 2010 Lancet, “National evaluation platform” concept
    • Untouched comparison areas don’t exist, roll-out often national
    • Dose-response analysis: implementation strength vs coverage change
    • Adjust for contextual factors that change over time
    • Monitoring data for the dose, household survey data for the response
  • Local stakeholders views
  • Data-informed platform for health (DIPH), dual-purpose
    • Feasibility studies in 3 countries
    • BMGF not keen on us being an implementation partner
    • Pilot work needed
  • Implementation strength systematic review
  • District level data for decision making systematic review
  • … but no innovations to study in 2010, 2011, 2012

To what extent do scaled-up innovations affect coverage of life-saving interventions and survival?

scale up coverage and survival country by country
Scale-up, coverage and survival, country-by-country
  • India
    • Undergoing rapid change given new “Technical Support Unit” to support GoUP
  • Nigeria
    • Scale-up of SFH innovations to Adamawa State
  • Ethiopia
    • Community-based newborncare (CBNC)
      • Design
      • Implementation strength: sensitive issue
      • Moving ahead …

To what extent do scaled-up innovations affect coverage of life-saving interventions and survival?

comment3
Comment
  • Implementation strength
    • Popular concept but not much relevant literature
    • Threat or opportunity?
    • Developing the methodology
  • Timing, time scale

To what extent do scaled-up innovations affect coverage of life-saving interventions and survival?

promoting best practice for policy
Promoting best practice for policy
  • Advocating use of best available evidence to influence policy decisions
  • IDEAS will:
    • Synthesise and disseminate maternal & newborn health research findings
    • Disseminate & publish IDEAS own findings
    • Promote exchange of learning
  • We aim to:
    • Inform donor strategies, both the Bill & Melinda Gates Foundation and others
    • Influence government policy in Ethiopia, Nigeria & India, and in other countries with high maternal and newborn mortality
    • Influence international policy makers, e.g. WHO
    • Contribute to future research programs.
technical resource centre
Technical Resource Centre
  • Provides support to BMGF implementation grantees in measurement, learning and evaluation
    • Continuous survey support to SFH
    • Time and motion study with SNL
    • Reviewing protocols, manuscripts
  • Lessons: 
    • Implementation grantees did not perceive a need for support and were initially defensive. 
    • MLE partner support should be built into the grant. 
    • Best success where project teams have a clear view of needs and we plan together
    • BMGF programme officers have a key role to play
communications resources
Communications resources
  • Website: blogs, news stories, interactive maps, events posts, image gallery
  • Quarterly newsletter: highlight IDEAS and grantee work
  • IDEAS twitter account
  • TRC web seminars – “how to” guides, technical issues, discussion of recent MNH papers

Website: ideas.lshtm.ac.uk

Newsletter sign up: eepurl.com/j3iBz

Twitter: @LSHTM_IDEAS

who are we
Who are we?
  • 23 staff
    • 20 in London
    • 1 Addis
    • 1 Delhi
    • 1 Abuja
  • 4 partner organisations
slide41
Highlights

Challenges

Change

Time-scale

Partnership not in contracts

Tension: project thinking and review of a long-term strategy

  • ‘Ringside seat’
  • Dedicated LSHTM team
  • Multi-disciplinary
  • ‘Nobody knows how to do this’
  • Practical, large-scale
  • Evaluation
contact us
Contact us

IDEAS Project

London School of Hygiene & Tropical Medicine

4th floor Keppel Street

London WC1E 7HT

Email: ideas@lshtm.ac.uk

Website: ideas.lshtm.ac.uk

Newsletter sign up: eepurl.com/j3iBz

Twitter: @LSHTM_IDEAS